A call to arms from guest blogger and University of Guelph professor, Dr. John Prescott:
Watching the global emergence and spread of multi-drug resistant bacteria is like seeing a train wreck in slow motion. There’s a sense of both inexorability and powerlessness. In the March 2013 issue of the Equine Veterinary Journal, Mark Bowen of the School of Veterinary Medicine and Science, University of Nottingham, writes that there is clear evidence of the need for change in our relationship with antimicrobials. Change is what many bacteria do for a living; of course the problem is not that bacteria change to resistance, but also that people are so resistant to change.
The excellent editorial (“Antimicrobial stewardship: Time for change”) describes the sensible steps taken by the British Equine Veterinary Association (BEVA) in 2012 to promote the stewardship of antimicrobial drugs in horses. These steps are summarized on the BEVA website: http://www.beva.org.uk/useful-info/Vets/Guidance/AMR. They provide an excellent approach to stewardship of antimicrobials in horses. BEVA has developed neat and simple promotional material to help equine veterinarians using these drugs do their part to help preserve them.
The BEVA project is summarized by the acronym PROTECT ME, which encompasses 9 steps to promote stewardship. PROTECT comes from for Practice policy; Reduce prophylaxis; Other options; Types of drugs and bacteria; Culture and sensitivity; Treat effectively, and ME come from Monitor and Educate. The brilliance and perhaps even contrariness of the BEVA approach is that it believes that policies should be created at the local level, and should be both dynamic and follow simple key concepts, rather than be national guidelines developed by people working in ivory towers.
The BEVA website provides the templates and forms for equine practitioners everywhere to develop simple and local policies that commit to stewardship. An important element in the PROTECT ME documents is to try to protect the drugs classified by the World Health Organization as the “Critically Important Antimicrobials” (3rd and 4th generation cephalosporins, fluoroquinolones). These drugs are categorized as “protected”. Drugs such as vancomycin and imipenem are categorized as “avoided”. The PROTECT ME approach promotes the use of “first line” antimicrobials as first choice for treatment of common conditions as part of the practice policy, and link this to the British “cascade” approach to antimicrobial drug choice. The BEVA approach is refreshing because it takes an intelligent, long-term approach that embraces the responsibility that users share to preserve the miracle while our scientists work feverishly to develop the next generation of antimicrobials. These are however going to be extremely expensive and perhaps also unavailable for animal use, except perhaps through the black market.
The antimicrobial “miracle drugs” revolutionized medicine and came into widespread use long before there was any science behind their optimal use. We’re still discovering how best to use them but we need to continue to develop strategies and approaches that optimize their use and minimize resistance and other side effects. The easily followed BEVA approach encourages user engagement with and responsibility for stewardship. Change is painful, but we have no choice. Let’s embrace it.